Download Preventing Cross-infection

CHAPTER
3
Preventing Cross-infection
Patricia Folan and Lesley Baillie
Preventing cross-infection is an essential activity for all nurses in their everyday practice.
Nurses have an ethical and legal duty to protect patients against infection (Cochrane
2000; Department of Health [DH] 2006a) but within hospital and residential situations,
where many nurses work, the risk of cross-infection is high. In any healthcare setting,
unless adequate care is taken, nurses can unwittingly transmit microorganisms from
one person to another. The media regularly report concerns about lack of cleanliness
and associated infection rates in hospitals and other healthcare settings.
Hospital-acquired infection, sometimes referred to as ‘nosocomial infection’, is
a serious problem, causing as many as 5000 patients’ deaths each year in the UK
(Pratt et al. 2001). With the increasing emphasis on community care, including
GPs’ surgeries and care homes carrying out invasive procedures, and earlier patient
discharges from hospitals, hospital-acquired infection often first becomes evident
in the community. The term ‘healthcare-associated’ infection (HCAI) is therefore
used more often now, defined as: ‘Infection acquired as a result of the delivery of
healthcare either in an acute (hospital) or non-acute setting’ (Pratt et al. 2007, S62).
The Nursing and Midwifery Council (2007) specified infection-control Essential
Skills Clusters for student nurses, all of which are incorporated in this chapter.
This chapter includes:
Principles for preventing healthcare-associated infection: an introduction
● Hospital environmental hygiene and multi-use equipment
● Hand hygiene
● Use of personal protective equipment including gloves, aprons and gowns
● Aseptic technique
● Specimen collection
● Isolation procedures
● Sharps disposal
● Healthcare waste disposal and linen management
●
Recommended biology reading
These questions will help you to focus on the biology underpinning the skills
required to prevent cross-infection. Use your recommended textbook to find out:
• What are microorganisms? Where are they found? Are all microorganisms
harmful?
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Preventing cross-infection
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Rheumatoid arthritis
An inflammatory disease
often affecting a number of
joints (initially smaller ones),
causing pain, swelling, stiffness
and deformity. It is often
accompanied by systemic
ill-health.
Type 2 diabetes
Type 2 diabetes develops
when the body makes
insufficient insulin, or when
the insulin that is produced
does not work effectively
(known as insulin resistance).
See www.diabetes.org.uk.
Infection
The successful invasion,
establishment and growth of
microorganisms within the
tissues of the host.
MRSA
A strain of Staphylococcus
aureus which is highly resistant
to many commonly used
antibiotics.
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Identify some of the beneficial roles of microorganisms.
How do microorganisms enter the body?
How are microorganisms classified?
What are the structure and properties of bacteria, viruses, prions, fungi, yeasts
and protozoa?
How do bacteria grow and multiply?
What factors influence the proliferation of microorganisms?
What is meant by the terms ‘commensal’, ‘pathogen’ and ‘normal flora’?
Distinguish between endogenous and exogenous sources of infection.
What mechanisms does the body employ to defend itself from infection?
Think about non-specific defences, e.g. secretions, reflexes, barriers etc., as
well as specific mechanisms. Review the structure of the skin.
How does the body fight infections?
What are the clinical signs of infection? What role does histamine play?
Which cells are involved in the specific immune response? Where are they
found?
What is the difference between humoral and cell-mediated immunity?
What are antibodies? How do they help protect us from infection?
How do we achieve an immunological memory?
What factors can affect an individual’s immune system?
PRACTICE SCENARIOS
As discussed above, prevention of cross-infection is part of the nurse’s role in all
practice settings. The following scenarios will be referred to throughout the text,
when discussing the practical skills covered in this chapter.
Adult
Mrs Winifred Lewis, aged 87, was widowed many years ago and lives in wardened
accommodation. She has a history of rheumatoid arthritis and type 2 diabetes, and
recently fell and fractured her hip. This was operated on in hospital but the wound
developed an infection, which grew MRSA. She was discharged home, under the
care of the district nursing team and intermediate care, but her wound deteriorated
and the surrounding skin showed signs of infection. Mrs Lewis appeared unwell and
dehydrated, so her GP requested readmission. She is now being isolated in the side
room of a surgical ward, and an intravenous infusion and intravenous antibiotics
have been commenced. She has a commode in the room and can transfer with help.
Learning disability
James Smith is a 59-year-old man with a learning disability who lives alone in a
farm cottage and works on the adjacent farm. Following an accident, James has
an open wound on his lower left leg that shows signs of infection. There is a large
amount of exudate, which has an offensive odour. The district nurse has been
visiting the farm to carry out dressings and a wound swab has been taken. James is
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Principles for preventing healthcare-associated infection: an introduction
Health Action Plan
A personal plan developed
for each individual who has
a learning disability, detailing
their health interventions,
medication, oral health,
nutrition, etc. (DH 2001).
67
keen to carry on with his usual work on the farm. The district nurse is liasing with
the community nurse for learning disabilities to help to teach James how to care
for his leg in between dressings. This information is now included in James’ Health
Action Plan. As the district nurse runs a clinic at the local GP’s surgery, James is
being encouraged to attend this for dressings instead of receiving visits at his home.
Mental health
Stacey is 28 years old and has been addicted to opiates for six years. She is living with
her parents who are very supportive. Recently Stacey began a community-based
detoxification programme with support from her local drug and alcohol team. During
detoxification, Stacey experienced severe withdrawal symptoms, including very high
blood pressure and vomiting. As a result she was admitted as an emergency to the
acute mental health admission unit. She arrived feeling very unwell, and soon after
arrival vomited over her bed. She was prescribed intramuscular metoclopramide (an
antiemetic) to stop her vomiting. Stacey is known to have hepatitis B.
PRINCIPLES FOR PREVENTING HEALTHCARE-ASSOCIATED
INFECTION: AN INTRODUCTION
Colonise
The establishment of
pathogenic microorganisms at
a specific body site with little
or no host response.This
can lead to a large number
of microorganisms, forming
a reservoir for infection and
cross-infection.
Many microorganisms exist but not all cause infection in individuals. Those that cause
disease are called pathogens. When pathogens are acquired from another person,
or from the environment, they are described as exogenous. The transmission of
pathogens, between people and across environments, is termed cross-infection. When
microorganisms colonise one site on the host and enter another site on the same person
causing further infection, this is called self-infection or endogenous infection.
In the third national prevalence survey (DH 2007a), the prevalence of HCAI
in England was 8.2 per cent, compared with 7.6 per cent for the UK and Ireland
collectively (excluding Scotland). The most common types of infections were
gastrointestinal system infections (22 per cent), urinary tract infections (19.7 per
cent), pneumonia (13.9 per cent) and surgical site infections (13.8 per cent).
LEARNING OUTCOMES
On completion of this section you will be able to:
1 discuss key policies influencing infection control practices;
2 identify the composition and role of infection control teams;
3 understand the chain of infection including the routes by which
microorganisms are spread.
Learning outcome 1: Discuss key policies influencing infection control
practices.
Concern about HCAI has led to many government publications, providing
recommendations for infection control. Clean, Safe Care: reducing infections and
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Preventing cross-infection
saving lives (DH 2008) provides an overview of initiatives in England. Key
publications are mentioned below.
• Saving Lives: Reducing infection, delivering clean and safe care (revised edition, DH
2007b). This provides evidence-based ‘high impact interventions’ (HIIs) or ‘care
bundles’ for key clinical procedures which can increase the risk of infection if not
performed appropriately. The HIIs highlight the critical elements of particular
procedures, the key actions required, and a means of demonstrating reliability
using compliance measurement. The HIIs aim to minimise unwarranted variation
in practice by identifying where compliance needs to be increased and measuring
how often all elements are performed for a given procedure. The tool enables
results to be quickly fed back to staff, actions can be agreed and implemented and
progress can be tracked.
• The Health Act: Code of Practice for the Prevention and Control of Health Care-associated
Infections (DH 2006a). This aims to assist National Health Service providers to plan
and implement how they can control HCAIs. It led to a legal requirement for acute
hospitals and other care providers to prevent infection. Failure to observe the Code
may result in an ‘improvement notice’ or ‘special measures’.
• National Evidence-based Guidelines for Preventing Healthcare-associated Infections
in NHS England (Pratt et al. 2007). In these updated DH-commissioned evidencebased infection control guidelines (referred to as EPIC2), the authors noted
that standard infection control precautions need to be applied by all healthcare
practitioners to the care of all patients. It is planned that revised guidelines will be
published in 2011.
The other UK countries’ administrations also provide guidance and policy on
infection control: for Scotland see www.hps.scot.nhs.uk; for Wales see www.wales.
nhs.uk; and for Northern Ireland see www.dhsspsni.gov.uk.
Standard infection control precautions relevant to all areas of practice are:
• hospital environmental hygiene;
• hand hygiene;
• the use of personal protective equipment;
• isolation of patients;
• the use and disposal of waste and sharps.
In this chapter you will encounter each of these precautions and focus on the skills
that are associated with them. These precautions are consistent with – and build on –
the ‘universal precautions’ that were established in the 1980s in response to the
growing problems of blood-borne infections. In the 1990s, the terminology changed
to ‘standard precautions’. Universal/standard precautions recognised a few simple
practices that could be used to care for all patients to minimise the risk of crossinfection to patients and staff alike. The National Institute for Health and Clinical
Excellence (NICE) (2003) produced guidelines for preventing HCAIs in primary
and community care. These apply the standard precautions of hand hygiene, use of
personal protective equipment and sharps disposal to various aspects of communitybased care.
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Standard precautions combine the major features of universal precautions and
Body Substance Isolation (BSI) and are based on the principle that all blood, body
fluids, secretions, excretions except sweat, non-intact skin and mucous membranes
may contain transmissible infectious agents. Standard precautions include infection
prevention practices that apply to all patients, regardless of suspected or confirmed
infection status, in any setting in which healthcare is delivered.
Learning outcome 2: Identify the composition and role of infection
control teams
As you read above, there are many national infection control policies. These are
implemented at local level by an infection control team (ICT).
ACTIVITY
When next in the practice setting, find out who the members of the local
infection control team are and where they are located. Also, find out where your
local infection control policy is kept and familiarise yourself with its content.
The ICT generally comprises an infection control nurse (ICN) and an infection
control doctor. Their roles include planning, implementing and monitoring the
infection prevention and control programme. They are available to offer advice on
all matters relating to infection control. They also provide education to healthcare
personnel and develop local policy. An infection control committee from a variety
of hospital departments provides advice and support for the ICT.
Many community healthcare trusts also employ ICNs who work closely with
the consultant for communicable disease control. The consultant is responsible
for monitoring and controlling the spread of infection in the community, as well
as other environmental hazards (Wilson 2006). Many hospitals also use infection
control link nurses (or ‘champions’) to improve awareness of infection control in
clinical areas. They receive basic training and help provide education, training,
audit and surveillance in clinical areas. There should also be close liaison between
the occupational health department and the ICT to ensure the health and safety of
patients and staff alike (Wilson 2006).
Learning outcome 3: Understand the chain of infection including the routes by
which microorganisms are spread
The ‘chain of infection’ can help you to understand how to prevent spread of
infection (see Fig. 3.1). Prevention of cross-infection is about breaking the chain of
infection. Each link in the chain will now be discussed.
Infectious agent
An infectious agent is a microorganism with the ability to cause disease. This
includes bacteria (most common in hospitals), viruses (more common in the
community) and fungi (e.g. Candida, which causes ‘thrush’). To identify the specific
infectious agent, specimens are collected and sent to the laboratory for microscopy,
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